Early Intervention in Psychotic Disorders: Challenges and Relevance in the Indian Context

Article excerpt

Byline: Matcheri. Keshavan, Amresh. Shrivastava, Bangalore. Gangadhar

Over the last two decades, there has been an increasing interest in the concept of early intervention (EI) in psychotic disorders, notably schizophrenia. Several lines of research underlie this emerging paradigm shift: (a) an increasingly well-established association between the duration of prolonged untreated illness and poor outcome; (b) evidence of progressive neurobiological changes in the early course of schizophrenia both in the pre-psychotic and psychotic phases, as evidenced by brain imaging studies in schizophrenia; and (c) emerging data, albeit preliminary, suggesting the efficacy and effectiveness of EI programs in improving the outcome in these patients. Mental health service systems across the globe, including Asian countries, have been incorporating specialized early intervention programs. However, literature on EI in the Indian setting is relatively sparse. In this article, we will review the rationale and approaches to EI and the application of these approaches to the Indian context, in light of the available literature. We also examine the constraints in the implementation of EI. Controlled data are needed to evaluate EI and the roadblocks to them, in order to implement EI in the resource-strapped mental health service settings in India.

Introduction

Schizophrenia is a highly disabling disorder prevalent worldwide, and is associated with increased mortality, poor quality of life, and low recovery rates. Over the past decade, there has been a great upsurge in the interest shown in studies focusing on EI in schizophrenia and related psychotic disorders. In this article, we briefly review the vastly expanding literature in this field, and focus on the rationale, the populations of interest, and the timing of EI approaches in psychotic disorders; we then review the approaches to EI with a view to identify evidence-based data. Finally, we will discuss the opportunities and challenges inherent in translating these models of care to mental health services in the Indian context.

Rationale for early intervention in psychoses

The rationale for EI has been largely derived from two lines of evidence. First, several studies have documented an inverse relationship between the duration of untreated psychosis (DUP) and outcome of schizophrenia. In a meta-analysis [sup][1] and a systematic review [sup][2] longer DUP was associated with poorer response to antipsychotic treatment on several measures. Similar observations have been reported in the Indian context. [sup][3] A recent meta analysis of five studies examining the association between DUP outcomes in the low- and middle-income countries found a significant negative correlation between DUP and improvement in symptoms after treatment. [sup][4] DUP, which reflects treatment delay, may be potentially reduced by early detection and intervention in developing countries. In a recent population-based study [sup][5] of patients with schizophrenia in a rural south Indian community, nearly two-thirds were not receiving medications, and the disability was significantly less in those who were receiving treatment. This highlights the importance of EI in the Indian setting.

Second, neuroimaging studies, using Magnetic Resonance Imaging (MRI), have observed a relationship between prolonged untreated illness duration, pronounced loss of gray matter volumes, and enlarged cerebral ventricles in patients with schizophrenia. [sup][6] First-episode patients also have less prominent structural brain abnormalities than chronically ill patients. As a more direct evidence of illness progression, prospective follow-up studies of first-episode patients suggest continued loss of gray matter during the first few years after the onset of psychosis. [sup][7] However, not all studies report a relation between DUP and brain morphological deficits from a series of cross-sectional neuroimaging studies. …